Application for Registration with ... .us



Application for Registration with the Petrofund Board as a Consultant

Under Minnesota Statutes Chapter 115C.11, all consultants who perform corrective action services in response to a petroleum tank release must register with the Petrofund Board. “Consultant” means an individual, partnership, association, private corporation, or any other legal entity that actually performs consulting services, which include the rendering of professional opinion, advice, or analysis regarding a release. As part of complying with the required registration criteria, consultants must complete this form and submit it together with the indicated documentation.

Registration is effective 30 days after a complete application is received by the board and remains in force until the expiration date of the registrant’s professional liability coverage, including pollution impairment liability; until voluntarily terminated by the registrant; or until suspended or revoked by the Commissioner of Commerce. If you have questions, please contact the Petrofund Information Line at 651-215-1775 or 800-638-0418.

1. APPLICANT INFORMATION

Full name of legal entity applying for registration:

DBA:

If the business is being operated under any name other than the exact corporate name, attach a copy of the Assumed Name Certificate filed with the Minnesota Secretary of State.

Address

City State Zip

Phone Fax

Primary contact

Legal entity (check one and attach a copy of the indicated documentation*)

( Sole Proprietorship (Assumed Name Certificate, if applicable)

( General Partnership (Assumed Name Certificate, if applicable)

( Limited Liability Partnership (Copy of filing from the Minnesota Secretary of State or state of domicile)

( Limited Partnership (Certificate of Limited Partnership filed with the Minnesota Secretary of State or state of domicile)

( Limited Liability Company (Articles of Organization filed with the Minnesota Secretary of State or state of domicile)

( Corporation (Articles of Incorporation filed with the Minnesota Secretary of State or state of domicile)

( Other legal entity (applicable certificate filed with the Minnesota Secretary of State or state of domicile)

*If the legal entity is organized under the laws of a state other than Minnesota, please attach a copy of the applicable foreign registration document (Foreign Corporation Registration; Certificate of Authority for a Foreign LLC; Foreign LP Registration; Foreign LLP Statement of Qualification) filed with the Minnesota Secretary of State.

2. BRANCH OFFICES

Please provide the following information for any branch offices that perform work at cleanup sites in Minnesota. Attach additional sheets if necessary.

Address

City State Zip

Phone Fax

Primary contact

3. CERTIFICATION

As legally certified with the authorized signature below,

Full name of legal entity

makes this application for registration with the Petrofund Board as a consultant and:

• certifies knowledge of and agrees to abide by the requirements of Minnesota Statute Chapter 115C and Minnesota Rule 2890;

• agrees to retain and make available for inspection all corrective action records for 7 years;

• agrees to maintain professional liability coverage, including pollution impairment liability, and agrees to submit a certificate or certificates verifying the existence of the required insurance coverage*; and

• agrees to file a corrected application for registration within 30 days if any of the information in this application becomes inaccurate or incomplete in any material respect.

*Please note that the company name listed as the “Insured” on the Certificate of Insurance must be identical to the company name listed on this registration application. The “Certificate Holder” section of the Certificate of Insurance must indicate: State of Minnesota, Department of Commerce/Petrofund, 85 – 7th Place East, Suite 500, St. Paul, MN 55101-2198.

| |NOTARIZATION |

| |Subscribed and sworn to before me this day of |

|Authorized signature |, 201 . |

| | |

|Name (print) |[Stamp] |

| | |

|Title | |

| |Notary Public |

|Date signed | |

| |Commission Expiration Date |

4. MAILING INSTRUCTIONS

Mail (do not fax) the following documents to the address below:

( this form with original signatures (a photocopy will not be accepted);

( the required documentation of legal status; and

( the certificate(s) verifying the existence of the required insurance coverage.

Minnesota Department of Commerce—Petrofund

Attn: Consultant Registration

85 Seventh Place East, Suite 500

St. Paul, MN 55101-2198

FOR OFFICE USE

Petrofund Consultant Registration Number

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